Personal formation and professional legacy

Born on 15 February 1856 into a cultured and musical family, Kraepelin was teetotal, an avid cyclist and a lover of the arts. Despite dismissal of his philological schooling in his ‘Memoirs‘, his writing was precise and evocative. In that volume he reflected on his academic influences, particularly Wilhelm Wundt (1832–1920), who established the first University Experimental Psychology laboratory in Leipzig and supported Kraepelin’s 1882 habilitation submission (comprising three published or soon-to-be-published articles). Kraepelin intended to build the scientific foundations of the specialty on experimental psychology. However, faced with failure in his pursuit of this, he changed his mind and research methodology, pivoting towards clinical research, i.e. cross-sectional symptomatology and illness course, histology, neurochemistry, genetics, ‘pharmacopsychology‘ and experimental psychology. In 1917, he founded the Deutsche Forschungsanstalt für Psychiatrie (now the Max Planck Institute of Psychiatry) in Munich, the first multidisciplinary postgraduate psychiatric research centre worldwide. His programme and practice widened the path for psychiatry to align more closely with medicine, and legitimated it as a clinical specialty throughout the 20th century and beyond. However, this achievement, to which we will return, runs parallel with another, darker legacy.

Eugenics, racism and the Nazi T4 programme

Kraepelin was a fervent nationalist and vocal advocate of eugenics during the German Empire (1871–1918). He saw mental illness through the lens of civilisation-induced, cross-generational hereditary degeneration, believing that society was being undermined by what he called the number of idiots, epileptics, psychopaths, criminals, prostitutes and vagrants,Footnote ^a and he linked mental illness to Jewish heritage in strikingly racist terms. Given his status, and couched in scientific language, these views helped legitimise the nascent field of racial hygiene. Although Kraepelin died in 1926, his legacy played a role in what followed.

Kraepelin head-hunted Ernst Rüdin (1874–1952), the first co-editor-in-chief of the ‘Archive for Racial Hygiene and Social Biology’, to lead the Genealogic Demographic Department at his institute (that would probably be called the psychiatric genetics unit or section today). Later, Rüdin co-authored the 1933 ‘Law for the Prevention of Hereditarily Diseased Offspring’ and, during the Nazi dictatorship, served as President of the Society of German Neurologists and Psychiatrists from 1935 to 1945. Senior psychiatrists helped develop and implement the Aktion T4 programme, with Rüdin in a central role. In 6 psychiatric hospitals converted to dedicated killing centres across Hitler’s Reich, T4 exterminated 80 000 neuropsychiatrically disabled people in Zyklon B gas chambers – kick-starting the Holocaust. The total number of victims with mental illness murdered in Germany and occupied countries during the period 1939–1945 far exceeded that number, totalling approximately 200 000 people. These atrocities are central to German psychiatry’s history; they need to be studied as having been committed 7–19 years after Kraepelin’s death, but they are linked to Kraepelin’s fellow-worker Rüdin. It is this historic German disaster that suggests we should continue to examine Kraepelin’s legacy, not only through his science but also acknowledging the ideologies he endorsed. ^{Reference Burgmair, Engstrom and Weber2}

Psychiatry’s medical ambitions and limitations

Kraepelin’s clinical rigour and descriptive precision shaped modern psychiatric diagnosis and helped medicalise the study of mental disorders. However, in his later work he recognised the inadequacy of rigid disease categories. Expressing doubt about his own foundational dichotomy between schizophrenia and bipolar disorder, he acknowledged variability within conditions and overlaps between them. However, this was by no means tantamount to a fundamental rejection of his postulate of the existence and scientific recognisability of ‘natural disease entities’ in psychiatry.

The limitations of Kraepelin’s clinical research method have been highlighted before, ^{Reference Engstrom and Kendler3} and recent voices ^{Reference Ikkos and Morgan4} have added to older ones to argue for a more culturally centred perspective to help the psychiatry and mental health fields move forward. However, based on his epistemology and methodology and the power of his textbook, Kraepelin’s achievement still stands and contemporary nosology systems, e.g. ICD and DSM, continue to use modified versions of his classification. Their utility as pragmatic constructs in diagnosis-related prescribing, research communication and public administration notwithstanding, currently clinically prevalent nosological classifications do not fit the data and diagnostic systems ‘lack validity’. ^{Reference Eaton, Bringmann, Elmer, Fried, Forbes and Greene5} Diagnostic categories are heuristics, not natural kinds. The hope of isolating discrete, biologically grounded disease entities has failed. ^{Reference Owen, Ikkos and Becker6} Despite massive investment in psychiatric neuroscience, the gap between research findings and clinical reality remains wide. Genetically, psychiatric diagnoses often represent overlapping, multidimensional spectra rather than bounded entities, although phenomenological psychopathology reminds us to respect the singular experiences that can arise with different presentations and conditions.

Kraepelin anticipated that biomedical research into mental illness would ultimately simplify an inherently complex field. However, a century after his death it has become apparent that, in doing so, he was overoptimistic. Dopamine is associated not only with psychosis but also with motivation, learning and pleasure. The hippocampus, a frequently studied brain structure, is pivotal to psychosis but also serves memory and is highly responsive to environmental factors, including psychological trauma. Genetic variations are correlated with psychiatric traits; however, correlations often span across various diagnostic categories and may also be linked to non-psychiatric or other traits such as creativity. While biological predispositions are significant, contemporary research highlights that gene expression is influenced by experience and context. Epidemiological studies reveal extensive ‘subclinical’ dynamics, including non-suicidal self-injury, subthreshold psychosis and postpartum depression, which are influenced by social stressors, peer interactions and cultural norms.

Science, stigma and critique

Kraepelin’s legacy is a paradox: the scientific impulse he championed has both advanced psychiatry and exposed its blind spots. Contrary to expectation, biomedical explanations for mental illness have not necessarily reduced stigma. Instead, they have too often reinforced notions of permanence, biological inferiority and otherness. Service users have offered trenchant critiques of scientific approaches that assume atomistic existences and risk de-subjectifying patients in order to produce statistical norms that separate groups and divide people into ‘us’ and ‘them’. ^{Reference Beresford, Ikkos and Becker7} Psychiatric diagnostic practices are fundamentally embedded in, and profoundly influenced by, broader sociopolitical factors, operating through intersecting ideas and institutional structures. The historical trajectory of psychiatric knowledge production demonstrates its dual function, both as a clinical intervention offered to people with mental illness and a regulatory apparatus for managing behaviours. And, as the history of degeneration and eugenics amply confirms, the specialty’s theories have interacted with social ideologies and broad culture. Is today’s social clamour for neurodiverse diagnoses likely to prove beneficent or harmful in the long term? Histories of psychiatry written as critiques of psychiatry have too often analysed only the spread of psychiatry’s influence across culture and society. A more robust analytic framework must instead account for the circulation of ideas and practices across science, culture and society. It has been, and remains, a powerful two-way process.

Kraepelin’s unexamined philosophical realism must not be misunderstood as monism. Following his teacher Wilhelm Wundt, he held a strongly dualistic view on the relation between mind and brain. However, and this is the decisive point here, his realistic approach led him explicitly to understand mental illness as a given ‘object’ that should be detected by research, not constructed or interpreted. As a consequence, he underestimated the relevance of subjective, relational and cultural dimensions of mental life. The current ‘biopsychosocial model’ has attempted to redress this imbalance but remains biologically centred in practice, at times declining to a ‘bio-bio-bio’ model.

In sum, despite its obvious shortcomings, the Kraepelinian order of discourse still governs large parts of psychiatric knowledge, dictates the rules of the game in research and defines clinical praxis. An alternative order of discourse struggles to replace it. We can point to at least three elements that have struggled to survive or break through:

1. (a) Kraepelin’s discourse frames psychopathology as a descriptive tool for diagnosing illness, rather than understanding the person revealed through mental suffering. Today, ‘psychopathology’ is often used interchangeably with ‘symptomatology’ – the study of symptoms to support diagnosis, prognosis and treatment. However, in its original ‘Jaspersian’ sense, psychopathology goes far beyond symptom classification. Rooted in phenomenology, it seeks to grasp the patient’s lived experience and relation to self and world. This approach, developed by Jaspers, Eugène Minkowski (1885–1972), Ludwig Binswanger (1881–1966) and others, rejects neurobiological reductionism, arguing that mental life cannot be reduced to brain functions alone – a stance with deep consequences for psychiatry’s conceptual foundations.

2. (b) Kraepelin’s legacy emphasises linking a morbid condition with a biological predisposition (diathesis) and a prognosis, often viewed as chronic (dementia praecox) or episodic (‘manic–depressive illness’). While this algorithmic approach suits other medical fields such as oncology, psychiatry’s focus on relational phenomena – shaped by context, social dynamics and care relationships – makes it less applicable. Legal scholar and artificial intelligence expert Pasquale criticises the reduction of complex human experiences to data points by opaque ‘black box’ algorithms, warning of their potential to harm, including in psychiatric care.

3. (c) The Kraepelinian model perpetuates the ‘myth of objectivity’. It frames the therapeutic relationship as an ‘I–It’ dynamic, where the patient is an object to be studied and treated, not a partner in dialogue. In contrast, Kraepelin’s contemporary philosopher Martin Buber (1878–1965) distinguished between the ‘I’ of ‘I–It’ relations (where the Other is an object of scrutiny) and the ‘I’ of ‘I–Thou’ encounters (where the Other is a genuine interlocutor). An ‘I–Thou’ relationship, however, is not merely ethically or epistemologically preferable, it can also fundamentally reshape the experiential frameworks of both therapist and patient. This is relevant to contemporary psychiatrists’ experiences of burnout and moral injury.

Psychiatry beyond textbooks

Born in 19th-century asylums, Kraepelin’s biomedical model has endured beyond deinstitutionalisation as psychiatrists have reshaped care aiming to treat people with schizophrenia and other disorders within inclusive communities. Both clinical diagnosis and diagnosis-related prescribing of psychological, pharmacological and physical interventions retain their place, and neurobiological research must continue. However, as we find ourselves in the age of artificial intelligence, political, economic and technological shifts have fragmented communities, displaced populations, nurtured inequality and social exclusion, damaged our natural environment and sparked new social movements, including those led by service users. Ikkos and Bouras ^{Reference Ikkos and Bouras8} and others have argued that these transformations – accelerated by COVID-19 – mark the advent of ‘Metacommunity Psychiatry’. Meta, from Greek for ‘after’, signals a shift beyond community psychiatry. Coined before Facebook’s rebranding, the term echoes wider transformations – technological, social, economic and biopolitical.

The metacommunity era mandates that, firmly established as a medical specialty, psychiatry defines more confidently its own standards, through a more ecological understanding of both brain and patient. ^{Reference Fuchs9} This requires prioritising the autonomous person in context and relationship and taking a ‘linguistic turn’. Language is the biologically evolved psychological foundation of human connection, expressed through speech, gestures, acts, images, art, culture and mass media. Without this focus, the ‘biopsychosocial’ model will remain an empty slogan and phenomenological and dynamic psychopathology and psychotherapy will continue to hobble. Closely related and equally vital is the need for deepening our dialogue with the humanities and social science and improving psychiatry’s understanding of their methods.

Psychiatry must centre the subjective experiences of service users and marginalised groups, ensuring that their voices shape practice, curricula and research. Training and continuing development should prioritise social determinants of mental health, equipping psychiatrists to challenge inequities and engage critically with capital, technology and systemic barriers. By forging alliances with service user advocates, stakeholders and policy makers, psychiatrists can help secure funding and drive structural change – bridging lived experience with public health, ecological and geopolitical realities.

Finally, while artificial intelligence promises transformative advancements, it also poses substantial risks. Mindful of the risk of another episode of dashed technological optimism in psychiatry’s history, and the ambiguous history of digital technology’s impact on the specialty and mental health to date, psychiatry must balance enthusiasm for innovation with critical evaluation of evidence to ensure passionate vocational commitment to every individual patient encounter and public mental health advocacy.

Psychiatry’s inability to define discrete diseases reflects scientific progress, not failure. While acknowledging its complex legacy, at the end of its long 20th century, 1899–2026, the field must accept the resulting uncertainty and engage more deeply with the realms of language, culture, technological change and political power. This shift should shape research, the curriculum, professional development, practice, ethics and public engagement.